Report from the Committee on Child Abuse and Neglect on “Evaluation of Suspected Child Physical Abuse” Imparts Guidelines for Pediatric Examinations
A recent clinical report published in Pediatrics, Vol. 119, Number 6, June 2007 by Dr. Nancy D. Kellogg and the Committee on Child Abuse and Neglect provides guidelines for the proper evaluation of suspected child physical abuse. Pediatricians, by properly detecting and reporting child abuse, can prevent further child abuse with much-needed education, referral, and support for children and families.
Among Kellogg’s recommendations were both a thorough examination of suspicious injuries and proper ancillary tests. The extent of testing should depend on the severity and type of injury, age of the child, and examination findings. According to Kellogg, the general rule is the more severe the injury and younger the child, the more thorough diagnostic testing should be. For skin injuries, Dr. Kellogg suggested measuring any bruises, bites, burns, lacerations, or other suspicious skin injuries. Pediatricians should pay particular attention to location (e.g. obscure sites, such as ears, neck, jaw) and note any patterns. To rule out non-accidental causes for bruising, such as hematologic disorders, Kellogg recommends CBC and platelet counts. A complete skeletal survey for fractures should include the following areas: humeri, forearms, femurs, lower legs, hands, feet, skull, spine, thorax, and pelvis. A CT scan can detect both intra-abdominal and cranial injuries. An MRI of the head/neck also serves as a means of detecting cranial injury. Assessing liver and pancreatic enzymes may be necessary for detecting intra-abdominal injury, which often presents without external signs of injury. Cardiac enzyme levels should be tested to rule out cardiac injury, which Dr. Kellogg suggests is rarely attributable to accidental causes. Radionuclide bone scans also test for skeletal abnormalities. A urinalysis can provide vital information regarding renal or intracranial injury. Diagnostic tests also provide a means for ruling out rare medical conditions that can cause skeletal injuries, such as osteogenis imperfecta (a congenital bone disorder characterized by bone fragility) and rickets.
Pediatricians can also screen for familial risk factors of child abuse, e.g., maternal depression, maternal substance abuse, spousal abuse, or other stressors. Physicians can provide education to parents who have unrealistic expectations regarding their child’s developmental capabilities. They should be able to discern whether the explanation given by the caregiver for the child’s injury corresponds with the pattern, severity, and age of the injury. Pediatricians should always carefully document the injury and their diagnostic impression of the caregiver’s explanation for the injury. Such documentation is vital for subsequent investigation.
Pediatricians must ensure that abused children are receiving the proper follow-up services. When abuse is suspected, child protection must be notified in order to ensure the safety of the child and meet any placement and/or plan of care needs for the family. The child’s primary care physician should be notified to ensure continuity of care. A referral should be made by the pediatrician for psychological services aimed at addressing the needs of not only the child, but those of siblings and the non-offending caregiver. For those children placed in foster care, proper documentation of medical charts at each doctor’s visit should be kept by foster parents in the form of medical passports. Pediatricians are the first line of defense in assessing and treating child physical abuse; however, the role pediatricians must not end there. Pediatricians are uniquely positioned to provide the resources necessary to prevent further abuse.
